Education for Hospital Waste Management

Dr Shyamala Mani, Centre for Environment Education

“This work is sapping”. Deepak points to one among them, ‘When he joined, he was very healthy. Now look at him’.

Vijay says,” This work of clearing the hospital’s garbage is exhausting and dirty. Sometimes, I don’t even feel like eating when I go back home. I just sleep. But what to do? In spite of being educated, didn’t get any job”. … ‘This is not work for men but for machines’ … ‘this is not even our work, but that of others. They are permanent, so they have paid the ‘afsar’, they get to keep drawing their salaries without ever coming for work. We are put in their places instead.’

The situation in other dumps catering to hospitals across the country is probably no different, if not worse. … irresponsible methods of waste management by the hospitals lead to not just environmental and public health hazards but also has the potential to severely affect the health of an unsuspecting population that handles hospital waste for a livelihood. Hence is it not the hospitals responsibility to take care of waste generated in their premises? Are there no binding rules on hospital which take care of this? This is important because health is linked to amenities like clean drinking water, sewerage systems, poverty, literacy levels and infrastructure. Higher government spending on healthcare can result in lower incidence of diseases especially communicable ailments.

According to ‘Healthcare in India’ published by the Foundation for Research in Community Health, among the leading causes of deaths in India, communicable diseases especially infectious, parasitic, gastrointestinal and respiratory diseases make up 43.3%. Similarly, prevalence of HIV infection has been on the rise in practically all states and all population groups in India. Nearly one in every 150 adults in India is infected.

New health problems such as drug resistant forms of several communicable diseases have emerged, including malaria, filariasis and multi-drug resistant TB.
Besides the known pathways or spread of communicable diseases, untreated waste-biomedical and others, also act as carriers or vehicles for microorganisms and cause injury to the people handling these wastes thus creating a portal of entry for these pathogens. The environment is also the reservoir for many unwanted chemicals which are genotoxins and these contribute to the decline of immunity amongst humans, animals and even damage the ecosystem’s ability to control or stabilize pathogenic microorganisms.

Labels for waste containers, developed by CEE. Colour-codes for waste containers for different categories of waste are specified by law. Segregation and treatment of waste at the site of generation must be promoted since if general and infectious wastes get mixed, then the whole waste has to be treated as infectious waste.
Growth of healthcare industry
The poor health status and high demand for services has led to a phenomenal growth of private healthcare establishments in the country.
Delhi has nearly 9000 establishments of which more than 50% are in the private sector. 99% of these healthcare establishments are small that includes nursing homes, private dispensaries, clinics and laboratories etc.

Although larger hospitals especially those providing secondary and tertiary care generate large amounts of infectious wastes, the scattered smaller establishments contribute to half of the infected biomedical wastes produced in Delhi. Many do not segregate their wastes or disinfect them before giving to common facility operators / service providers. At least parts of these wastes are deposited in municipal bins, making the entire municipal waste infectious. Thus the total quantity of infectious wastes increases, which can contribute to the increased morbidity in the city.

To address this problem, an integrated waste management plan involving the coordinated working of several departments in a health-care establishment such as housekeeping, engineering, laundry, kitchen, security, yard supervisor besides nursing, medical, surgical, laboratory and administrative departments, needs to be put in place.

Many health-care settings may have had incinerators for incinerating pathological waste and body parts earlier. These can no longer be used since most cities in India have banned their use except in common facilities located several kilometers away from the city.

There is a need to set up more model common facilities in each state and systems for collecting and storing separated waste and safely transporting the waste. Autoclaving and shredding which is not there in many of the healthcare establishments, needs to be set up either in-house or at common facilities.

The most important component of all is the education and training aspect of the integrated waste management plan which involves not only training of several medical, para-medical and non-medical employees of the establishments for source reduction, segregation, disinfection, transport, treatment and disposal, but also creation of awareness among public, public servants, professionals and the government for taking serious note of the consequences of improper management of hospital waste.

Provisions for protective gear for healthcare staff are part of an integrated healthcare waste management system.
The Biomedical Waste (Handling and Management) Rules 1998 have categorised the various types of wastes generated in healthcare establishments methods that can be used to treat and dispose these. The subsequent amendments also suggest how large and small hospitals can manage their wastes and make use of common facilities to treat wastes. These Rules and their implementation have brought about a degree of awareness and concern among those managing healthcare establishments.

Way Ahead
Formation of professional associations like National, State and District Hospital Waste Management Associations, Infection Control Committees and cells and special groups among the Municipal Solid Waste Associations, Municipalities and Corporations and other relevant bodies for carrying out advocacy through them and through various national and international conferences on various issues of Hospital Waste Management and developing plans through them for awareness among public, establishing model waste management in hospitals, common facilities, monitoring and evaluation helps greatly in taking the movement forward and achieving tangible results. This is what the Indian Society for Hospital Waste Management and the Hospital Infection Society of India; NGOs like CEE and Toxics Link have been doing in India.

Management of Hospital Waste involves not only the medical fraternity but several other professional groups, NGOs and the common people.

Without their conscious effort not only at hospitals and clinics but even their homes, where a lot of treatment occurs these days, the spread of infection from the hospital waste cannot be contained. Their awareness and education through the media and other means like door-to-door motivation is all important. College students, youth, women’s groups and service clubs play a vital role in spreading awareness and can combine these with programmes they are already involved with like AIDS awareness. Even school children need to be conscientisized towards this immense problem and from a young age should adopt practices, which along with personal hygiene habits helps them demonstrate responsible behaviour for their safeguard and those of others as well.

CEE’s Health-Care Establishment Waste Management and Education Programme (HEWMEP)
STEP 1: Waste reduction
STEP 2: Segregation at Source
STEP 3: Separation of glass sharps
STEP 4: Disinfection by dipping IN 10% bleach or sodium hypochlorite for 6-8 hours
STEP 5: Transport and routing of Hospital Wastes from different zones and wards to the place of treatment
STEP 6: Autoclaving/Microwaving of waste and shredding (for plastics, and metal sharps)
STEP 7: Incineration/Deep burial (for pathological and anatomical waste)
STEP 8: Radioactive waste must be stored in lead containers according to BARC Regulations for ten half life period for radioactive decay of the wastes
STEP 9: Cytotoxic waste — Deep burial/ land filling in hazardous waste site
STEP 10: General waste
• Composting of kitchen waste
• Recycling for Office and packaging waste, confidential paper to be Shredded zand then sent for recycling
STEP 11: Hazardous chemical plastics should not be shredded. Separate collection for these should be organized for making into structurals such as girders for buildings, culverts, lamp posts and telephone poles etc. or for burying in hazardous waste landfills
STEP 12: Training and education at all levels within the healthcare establishment/s and outside for achieving the above steps

As an NGO and a part of the concerned public, CEE tried to assess whether the wastes actually being managed in the healthcare establishments led to reduction in infection levels and whether the knowledge, attitudes and practices of the healthcare staff had any relation with the changed infection status in a healthcare setting.

This was studied by evaluating the infection status in several healthcare establishments of different sizes in Delhi, Pune, Kannur, Gulbarga and Bhubaneswar and is being continuously checked in other places too. The knowledge, awareness/ attitudes and practices (KAP) of doctors, nurses and housekeeping staff of these establishments who are primarily concerned with waste generation and management were assessed using carefully designed KAP questionnaires. This was followed by a cross sectional study of biomedical wastes generated in all healthcare establishments, research institutions in Delhi and many other states throughout the country. The profile status of all these institutions towards handling and management of wastes was assessed using interview schedules and observation tables. Standard methods were used to check the infection status in correlation with KPA and profile scores in all the locations. A practical and ongoing training schedule for the staff was evolved, conducted and several educational material in different languages were developed for training and reinforcement.

The KAP and profile tests were repeated. Scoring of the KAP and profile scores and the actual infection status after training showed that the awareness and best practices status of the HCEs directly impacted their infection status. We have found that in addition to development of safe transport, treatment and disposal facilities, a customized awareness and training programme is essential to control the spread of infections from biomedical waste.

For more information contact:
Dr Shyamala Mani
Waste and Resource Management (WaRM)
Centre for Environment EducationC-40, Ground Floor, South Extension Part 2
New Delhi 110049
Ph: 011-26262878/81; Fax: 011-26262880

Healthcare waste is different from our domestic waste and must be segregated, collected, stored, transported and disposed properly. If it is not managed in accordance with set guidelines, it can get mixed with general waste within the hospital and subsequently with solid and liquid municipal waste outside. This can expose the entire community to highly infectious diseases like HIV, Hepatitis B, C, Tuberculosis and other skin and respiratory aliments.

In order to enhance awareness about biomedical waste management, CEE has created a variety of general awareness materials such as cinema slides and a website. More detailed educational material have been developed as a kit for healthcare professionals including a booklet on the legislation, FAQs, sample stickers for waste containers, poster on pre-treatment processes etc.

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